Please indicate if any and which of family members have had any of the following condition(s):
YOUR HEALTH HISTORY
Please indicate if any of the following condition(s)
HISTORY OF VACCINATIONS (FOR CHILDREN ONLY):
I UNDERSTAND THAT MY INSURANCE COMPANY MAY NOT REIMBURSE FOR THE EXPENSES INCURRED AT THIS OFFICE. I UNDERSTAND THAT I AM FULLY RESPONSIBLE FOR ALL DEBT.
I understand a 24 hour advanced notice is required when canceling my appointment and if there is not a 24 hour notice given, I will be billed $65.00 for a late cancellation fee
I understand that if i do not keep my appointment and do not call to cancel or reschedule, I will be billed $75.00 for a no show fee.